Reliable Health & Rehab At Lakewood
RELIABLE HEALTH & REHAB AT LAKEWOOD in ATLANTA, GA — inspection on April 30, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
at 10:52 AM in R92's room revealed an open box of Name brand Classic lubricant eye drops on the
11:42 AM with Certified Nursing Assistant (CNA) AA revealed no residents self-administer
on the lookout for any items residents were not supposed to have, including medications and other items, for safety purposes.
She stated the facility's protocol when prohibited items were found was to let a nurse know, and the nurse then got a supervisor involved.
She stated that when she previously reported eye drops to nursing, she was told R92 could have them because he was independent.
She stated the potential negative outcome related to the eye drops being unsecured at the bedside was that another resident could access them and ingest them, causing harm.Interview and observation on 04/28/2026 at 12:53 PM with the Infection Preventionist (IP) revealed she had the two boxes of Name brand Classic lubricant eye drops in her hands.
The IP revealed R92 had an order for eye drops and stated he must have received the eye drops from the Veterans Association (VA).
She stated he did not care what they told him.
She stated he should not be having the Name brand Classic lubricant eye drops because it was a hazard for other people.
Any residents could come in and take eye drops, could drink the eye drops and could cause harm.
Interview on 04/28/2026 at 1:34 PM with the Administrator revealed that typically if a resident had medications at the bedside, the resident would need to be assessed for self-administration of medications.
She stated the resident should not have eye drops in his room.
She stated the potential negative outcomes included another resident accessing the items and adverse effects related to ingestion.
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Reliable Health & Rehab at Lakewood 1980 Arrow Street, SW Atlanta, GA 30310
During initial screening and observation on 04/28/2026 at 10:07 AM, several ceiling tiles revealed tannish-brown stains, varying in size, located near the facility nurses' station on the side that you would approach the desk.Observation on 04/28/2026 at 11:12 AM, noted the presence of brown rings, roughly 16 inches in diameter, on the ceiling tiles located directly above the bed in room [ROOM NUMBER]A.Observation on 04/30/2026 at 10:47 AM, several ceiling tiles contained stains in circular shapes and variation in sizes located near the facility nurses' station.Observation on 04/30/2026 at 10:51 AM in the glass day room, specifically near the window in the seating area above a resident's chair, two ceiling tiles were noted with stains, each exhibiting brown circular stains approximately three inches in diameter on each side.Observation on 04/30/2026 at 11:00 AM, the east hall's ceiling tiles revealed a brown circular shape approximately 10 inches in diameter on the ceiling tile in the middle of the hall.Observation on 04/30/2026 at 12:30 PM noted a white, moldy substance on the ceiling tile near the facility nurses' station.Interview and observation during the walking tour on 04/30/2026 at 11:04 AM, the Maintenance Director inspected room [ROOM NUMBER]A and noted the ceiling tiles exhibited tan and brown stains, along with bulging.
The Maintenance Director indicated that this issue was a result of rain; however, there was a risk that the tiles could fall on the resident. It was confirmed that immediate replacement was necessary.
Additionally, he verified that two separate ceiling tiles in the glass dayroom also displayed tan and brown stains.
Furthermore, he confirmed the presence of several circular brown stains of varying sizes located near the nurse station.Interview and observation on 04/30/2026 at 11:38 AM with the facility Maintenance Director on the east hall revealed that the Maintenance Director was in the process of replacing the ceiling tile subsequent to the photograph being taken, but he verified the existence of the discolored ceiling tile.Interview on 04/29/2026 at 2:14 PM with the Administrator disclosed that there were leaks in the roof, which was repaired on 12/16/2025.
She confirmed that the brownish stains were due to recent rainfall.
She mentioned that she had been conducting daily inspections and had not observed any issues, having performed rounds on 04/28/2026.
Nevertheless, stains were appearing as a consequence of leaks from the rain that fell yesterday.
She shared there was a potential risk of tile overload that could drop on a resident.
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Reliable Health & Rehab at Lakewood 1980 Arrow Street, SW Atlanta, GA 30310
reported the incident to the Director of Nursing (DON) and the charge nurse.Review of a second
pants.Review of progress notes revealed a nurse's note dated 01/09/2026 at 1:22 PM documenting:
her pants.Review of a nurse's notes revealed a note dated 01/09/2026 at 1:48 PM that documented: Call placed to 911.
Awaiting arrival. A nurse's note dated 01/09/2026 at 5:37 PM documented the responding law enforcement officer's name, badge number, and case number.Interview on 04/30/2026 at 9:22 AM with the Administrator revealed a CNA notified the nurse after observing R12 in R113's room with his right hand in her pants while she was seated in her wheelchair.
She stated there was no evidence that he had gone into her brief and a skin assessment was conducted with no findings.
She stated that R12 was immediately removed from the room and escorted to another room.
She stated the facility immediately followed protocol, law enforcement was contacted, the family was notified, and the incident was reported to the state and to corporate office.
She stated R12 was sent to the acute care hospital, and the facility conducted an abuse in-service and initiated an investigation.
She stated through the investigation it was found that R113 unintentionally called people to come to her room, and the facility care planned this behavior.
She stated R12 was diagnosed with a urinary tract infection (UTI) upon admission to the acute care hospital and was subsequently moved from the west hall to the south hall, as the south hall houses primarily male residents.
She confirmed the abuse allegation was substantiated.
She stated the potential negative outcome was that if he had gotten into her brief, he could have sexually assaulted her, and she would not have been able to communicate it.
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Reliable Health & Rehab at Lakewood 1980 Arrow Street, SW Atlanta, GA 30310
plan was missing components of standards of care for a Foley catheter, as was the physician's order.
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Reliable Health & Rehab at Lakewood 1980 Arrow Street, SW Atlanta, GA 30310
PAR.Interview on 04/28/2026 at 12:53 PM with the MDS Coordinator BB revealed that R92's
non-smoking facility in 2020 and she became aware of R92 smoking in the facility since that time.
She
meeting with the Veterans Administration (VA) regarding discharge.Interview on 04/30/2026 at 10:22 AM with the MDS Coordinator BB revealed she stated the care plan should have been updated to reflect the interventions put in place for the resident related to his non-compliance with the smoking policy.
She stated the failure to update the care plan was an oversight.
She stated the potential negative outcome was that no one would have known about his non-compliance with the smoking policy, and that he could have brought danger to other residents.Interview conducted on 04/30/2026 at 9:22 AM and 04/28/2026 at 1:34 PM with the Administrator revealed the care plan should have been updated to reflect the new interventions related to the resident's non-compliance with the smoking policy.
She stated she did not know why the care plan was not updated.
She stated her expectation for the Minimum Data Set (MDS) Coordinator was to update the care plan to reflect interventions when they were put in place.
She stated the potential negative outcome was that other nurses would not be able to see the new interventions that were put in place for the resident.
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Reliable Health & Rehab at Lakewood 1980 Arrow Street, SW Atlanta, GA 30310
She stated interventions in place included placement of a smoke detector in his room and daily room
had instructed nursing to check him upon return from outings.
She stated the facility was not
potential negative outcome related to the vape pen was fire risk and respiratory harm to R92 and other residents.Interview on 04/28/2026 at 1:34 PM with the Administrator revealed she stated R92 was very non-compliant and cursed at staff when they attempted to redirect him.
She stated he went out frequently and returned with smoking items, and that every time staff had observed him with smoking paraphernalia, it had been confiscated.
She stated the facility became a non-smoking facility in 2020 and first observed R92 being non-compliant with the smoking policy in 2025, with vaping becoming more frequent in 2026.
She stated interventions included smoke detectors in his room, frequent rounds every two hours with visual checks for smoke, and relocation of his room closer to the nursing station.
She stated the facility did not maintain logs of the every-two-hour rounds conducted in his room.
She stated the potential negative outcome of R92's smoking behavior was that if he were to drop ashes, the facility could catch fire.
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Reliable Health & Rehab at Lakewood 1980 Arrow Street, SW Atlanta, GA 30310
Based on observations, staff interviews, and review of the facility's policy titled, Medication Storage
potential to create a hazardous condition in which any resident could access the treatment cart and come into contact with topical creams that could be toxic if ingested.
The census was 94.Findings include:
Review of the facility's policy titled Medication Storage in the Facility, effective date 10/01/2025, revealed under Policy: .
The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
Section B revealed that Medication rooms, carts, and medication supplies are locked or attended by authorized personnel. An observation and interview on 04/29/2026 at 9:35 AM revealed that, after observing wound care for R3 with the Wound Care Licensed Practical Nurse (LPN), the treatment cart was left in the [NAME] hall, across the hall from R3's room, which was been unlocked and unattended for 30 minutes. An interview with the wound care LPN revealed that he confirmed the treatment cart was unlocked and unattended. An interview with the Infection Preventionist (IP) LPN on 04/29/2026 at 11:09 AM revealed that she had spoken with the wound care nurse about this after the incident.
She confirmed that he told her the treatment cart was left unlocked.An interview with the Administrator on 04/30/2026 at 1:40 PM revealed that she expected all medications, including topical medications, to be locked when not in sight of a licensed nurse or authorized person.
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Reliable Health & Rehab at Lakewood 1980 Arrow Street, SW Atlanta, GA 30310
laundry.
This deficient practice had the potential to cause the spread of infection throughout the
and Control Program, reviewed 01/06/2026, under Policy Explanation and Compliance Guidelines revealed: .12.
Linens: b.
Clean linen shall always be separated from soiled linen.
Review of the facility's policy titled Handling Soiled Linens reviewed February 2024, revealed under Policy Explanation and Compliance Guidelines: . 11.
Soiled linen shall always be kept separate from clean linen.An observation of the laundry area on 04/30/2026 at 10:25 AM revealed that all doors to the washers and dryers were open upon entering the clean linen area.
The clean linen, sheets, towels, blankets, and washcloths were folded on the table to the left of the washer and dryer room.
Next to the dryers on the right side of the room were residents' clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes, all next to the dryers and directly in front of the dirty laundry room that had an open door allowing exposure of possible pathogens from the dirty laundry to the clean resident clothes. It was also observed that, to bring the dirty clothing and linen to the washer, the dirty barrels had to be pushed past the clean clothing on the racks. An interview with Environmental Staff DD and EE, who were working in the laundry on 04/30/2026 at 10:30 AM, revealed that they felt they had reduced the spread of infection by keeping all doors open, covering the dirty barrels, and circulating the air.
They revealed that the one rack of clothes (not covered) and the bagged clothes on the floor next to the dirty area were no-name clothes that were sometimes distributed to residents in need.
The rack of clean clothing parked in front of the open door to the dirty linen room was personal resident clothes that need to be distributed.
They stated that the staff member who distributed clean clothes worked only at night, when the clothes were delivered to the residents.An interview with the Environmental Services Director on 04/30/2026 at 11:00 AM revealed that the door to the dirty side of the laundry should always be closed and that there should be no linen on top of the dirty barrels.An interview with the Infection Preventionist nurse on 04/30/2026 at 11:50 AM revealed that when she was shown pictures and concerns about cross-contamination between dirty and clean laundry, she confirmed there was a problem with cross-contamination in the laundry, but she was not aware of the concern until then. An interview with the Administrator on 04/30/2026 at 1:40 PM revealed that the residents' clothes should not be where they were at this time; they should be handed out immediately once they were clean.
She expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes, and a negative outcome could be the spread of infection through the laundry.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.